Coping behavior and depression of patients with affective disorders: a systematic review of the literature

Borovikov Andrei Vladislavovich Independent researcher 83 Tchaikovsky St., Saint Petersburg, 191123, Russia alohaman1999@gmail.com

Introduction

Modern people face various psychosocial stressors on a daily basis, which are known to be important etiopathogenetic factors in the development of depression. A number of studies indicate that various types of stressors — critical life events, daily difficulties, and chronic stress — are predictors of the development of depression ^{[37, 39, 40]} and are associated with the clinical characteristics of depression ^{[30, 31, 52]}. However, most people who are affected by stress do not develop mental disorders, including depression. It is assumed that this is facilitated by adaptive mechanisms that ensure the process of adaptation to changing living conditions at the biological, psychological and social levels. In particular, coping behavior (coping) is one of these mechanisms as a way of regulating adaptive resources, as well as their organization in the structure of the adaptive response ^[7].

There are many definitions of coping, due to the variety of approaches and directions in its research. For example, coping is the use of cognitive and behavioral strategies to manage the demands of a situation that is assessed as burdensome or beyond a person's capabilities. Coping is aimed at reducing negative emotions and conflicts caused by stress ^[70].

Coping behavior is a broad concept, so there are many classifications describing different types and ways of coping with stress ^[28]. The most famous classification was proposed by R. Lazarus and S. Folkman. The authors identified two main types: 1) problem-oriented coping, aimed at solving the problem causing distress (for example, drawing up an action plan); 2) emotion-oriented coping, focused on managing emotions (for example, self-control and avoidance) ^[43]. Another classification method is based on the division of coping according to the principle of "engagement — detachment" (Eng. "engagement — disengagement"). Engagement involves actively dealing with stress or emotions related to distress. This type of coping includes problem-solving coping, as well as coping forms aimed at managing emotions (for example, acceptance and cognitive restructuring). Detachment (or avoidant coping) involves avoiding threats or related emotions and includes coping behaviors such as denial, avoidance, and wishful thinking. Avoidant coping is usually ineffective for reducing stress in the long run, as it does not eliminate the threat itself and its consequences ^[13].

Coping with stress can have an impact on health, as well as on the development of mental disorders, including depression ^{[1, 14]}. People suffering from depression often underestimate the controllability of stressors and exhibit more passive behavior. Depression can also be considered as a specific model of coping with stress ^[1].

The last review on coping and depression in patients with affective disorders was conducted in 2005. M. Christensen and L. Kessing included 11 cross-sectional and 17 longitudinal studies in their work. The authors found that in only four studies, the results indicate the role of emotionally-oriented coping and/or avoidant coping in the risk of developing affective disorders. Most of the studies included in the review indicate that emotionally oriented and avoidant coping strategies are associated with the severity of depression and recurrence of depressive episodes. In addition, M. Christensen and L. Kessing note that problem-oriented strategies seem to be associated with a positive outcome. However, the results of longitudinal studies included in the review do not provide consistent evidence supporting this conclusion ^[17].

Almost 20 years have passed since the last review of coping and depression in patients with affective disorders, and many new studies have been conducted during this period. In this regard, there is a need to update and systematize scientific data for a deeper understanding of the features of the depressive state in patients with affective disorders. The aim of the study is to identify and summarize existing scientific data on the features of coping behavior in patients with depression within the framework of affective disorders.

The main objectives of the study:

1. Determine the nature of the relationship between the symptoms of depression and the types / methods of coping.

2. To determine which types and methods of coping predict the development of depression within the framework of affective disorders.

3. To determine the features of the repertoire of coping behavior in patients with depression in comparison with mentally healthy individuals and patients with other mental disorders.

Materials and research methods

Selection criteria

This review was conducted based on the PRISMA criteria for writing systematic reviews and meta-analyses ^[46]. To achieve the purpose of the study, a structured approach was used, which includes five components. The acronym "PICOS" is used to designate these components: the patient population or the diseases under consideration (P — Population), interventions or impacts (I — Intervention), the comparison group (C — comparator group), the result or endpoint (O — outcome) and the study design (S — study design). The following criteria were selected for this review:

P: Depression in patients with affective disorders (unipolar and bipolar depressions). In addition, work focused exclusively on adolescents or elderly patients was excluded. Studies in which depression was studied in the context of chronic somatic diseases were also excluded.

I: The study should include a detailed description of diagnostic procedures and research methods.

S: Healthy people and patients with mental disorders.

A: Quantitative and qualitative characteristics of coping behavior.

S: Descriptive, observational, and interventional research designs. Individualized designs (clinical case and series of clinical cases) were excluded. Methods: quantitative, qualitative and mixed.

Additional inclusion criteria were the language of the publication (Russian or English) and the type of publication (full-text and publicly available).

Research search and selection strategies

Firstly, using specific keywords, a systematic electronic search was conducted in three databases: PubMed, eLibrary.Ru and Google Scholar.

Description of the search strategy in the PubMed electronic database. Main search criteria: full text for free. Additional criteria: articles in English; people; age "19 years and older". The advanced search constructor "Title/Abstract" was used with terms from two categories: 1) nosology: depression, depressive symptoms, depressive disorder, major depression, affective disorders, bipolar disorder, bipolar affective disorder; 2) coping behavior: coping. The following terms were used to narrow down the output results: cancer, AIDS, HIV, transplant, transplantation, coronary, cardiac, hypertension, heart, postpartum, pregnancy, hemodialysis, diabetes, arthritis, migraines, insomnia, chronic pain, asthma, children, elders, elderly, older adults, teenagers, adolescents.

Description of the search strategy in the Google Scholar electronic database. An advanced search was used: the terms are found in the title of the article. Terms from two categories: 1) nosology: depressive disorder, major depression, affective disorders, bipolar disorder, bipolar affective disorder; 2) coping behavior: coping. Excluded words: cancer, AIDS, HIV, transplant, transplantation, coronary, cardiac, hypertension, heart, postpartum, pregnancy, hemodialysis, diabetes, arthritis, migraines, insomnia, chronic pain, asthma, children, elders, elderly, elderly, adolescents.

Description of the search strategy in the electronic database eLibrary.Ru . The search was carried out by publication names, annotations, and keywords. Types of publications included in the search: journal articles, conference materials, dissertations. Search parameters: search in publications with full text on eLibrary.Ru; search in publications available to the user. Combinations of English words were used: 1) nosology: depressive disorder, major depression, affective disorders, bipolar disorder, bipolar affective disorder; 2) coping behavior: coping. In addition, combinations of Russian words were used.: 1) Nosology: depressive disorder, major depressive disorder, affective disorders, bipolar disorder, bipolar affective disorder; 2) coping behavior: coping, coping, coping behavior.

Secondly, a manual job search strategy was used.

Articles published from 1980 to November 2024 were selected.

Encoding of results

Since the researchers used various methods of coping assessment (see the results — Methods of psychological diagnosis of coping), they were recoded into the following types of coping: problem-oriented coping, emotionally oriented coping aimed at detaching from a stress situation (EOC), and emotionally oriented coping aimed at involving in a stress situation (EOC).

The division of emotionally oriented coping into two types - EOKO and EOKV — is explained by the fact that some strategies of emotionally oriented coping are associated with involvement in a stress situation, while others are aimed at avoiding stress. Problem-oriented coping has not been separated, as it is considered as a form of involvement in a stressful situation.

One researcher participated in the transcoding of the results.

Results

Stages of publication selection:

The stage of identifying publications from databases and using a manual search strategy. A total of 2,129 publications were identified: eLibrary.Ru (n = 89), Google Scholar (n = 319), PubMed (n = 1660), manual search (n = 61). After eliminating duplicates (n = 1751): eLibrary.Ru (n = 69), Google Scholar (n = 265), PubMed (n = 1356), manual search (n = 61).

The stage of screening publications. Publications that have been screened by title and annotation: eLibrary.Ru (n = 6), Google Scholar (n = 40), PubMed (n = 18), manual search (n = 61). Combining data and redoing duplicates: 125 publications were identified in total, 112 after duplicates were eliminated.

The stage of publication selection. During the analysis, publications were excluded for the following reasons: inconsistency of the study population (n = 42), the text is unavailable (n = 23), a clinical case (n = 1), the described results do not relate to coping (n = 4).

After applying the selection criteria, 42 papers were included in the review. Of these, 27 studies had a cross-sectional design (see Table 1), and 15 had a longitudinal design (see Table 2). In 8 studies, the same population was studied ^{[10, 20, 21, 32, 34, 41, 64, 71]}.

The largest number of works are presented by authors from the USA ^{[10, 20, 21, 32, 34, 41, 64, 67, 71]}. Four studies from Russia ^{[2, 3, 5, 6]}, Three papers each come from the Netherlands ^{[11, 54, 57]}, Canada ^{[47, 51, 63]}, Japan ^{[58, 69, 72]} and Turkey ^{[25, 29, 73]}. Two studies from India ^{[16, 23]}, Poland ^{[55, 56]}, the Republic of Korea ^{[53, 62]} and Australia ^{[26, 27]}. According to one publication from Hungary ^[65], Belgium ^[48], Italy ^[22], Singapore ^[33], the Czech Republic and Slovakia ^[36], Switzerland ^[59], Ukraine ^[49], Romania ^[19], one work was carried out by an international team ^[24].

The main socio-demographic and clinical characteristics of the population.

6816 respondents with depression within the framework of affective disorders participated in the analyzed studies. The calculation includes patients who have completed the study. One study was excluded from the calculation because data on the number of respondents with affective disorders were not provided ^[63].

The average age of the respondents was 42 years. Fourteen studies were not included in the calculation of average age. In 7 studies, age characteristics are not described or age is presented as a range for the study population. ^{[3, 5, 6, 16, 41, 49, 63]}. In 5 studies, age characteristics were calculated for the initial population, some of which did not complete the study. ^{[20, 21, 32, 34, 64]}. In one study, the age was calculated for the control and clinical groups ^[26], and in another study, different age groups were considered ^[53].

The majority of respondents were female (62%), respectively 38% were male. The calculation did not take into account studies where the gender distribution was presented for the initial group. ^{[20, 21, 32, 34, 64]}, either the ratio of men and women is not described ^{[5, 57, 63]}, or the calculation was performed for the general sample ^[26]. Distribution by clinical groups: unipolar depression — 93%, bipolar disorders — 6%, other affective disorders — 1%.

Methods of psychological diagnosis of coping

Quantitative methods of coping assessment were used in all studies. The most common assessment methods were the following methods: in 9 studies, the "COPE" questionnaire was used." ^{[19, 24, 25, 29, 47, 55, 56, 67, 73]}, "The Health and Daily Living Form" was used in 6 papers" ^{[10, 20, 21, 41, 64, 71In 6 studies, various variants and modifications of the questionnaire of coping strategies by R. Lazarus and S. Folkman were used [5, 6, 47, 48, 53, 65]}, A short version of the COPE questionnaire was used in 5 papers ^{[16, 23, 26, 27, 33]}, in 4 studies — "The Copying Inventory of Stressful Situations" ^{[51, 58, 62, 69]}, The questionnaire Mechanisms of coping behavior by E. Heim was used in 3 works ^{[2, 3, 49]}, in 3 publications "Utrecht Coping List" ^{[11, 54, 57]}. Two studies used the "Cognitive Emotion Regulation Questionnaire" and "Responses to Positive Affect questionnaire" as an assessment of the cognitive coping style ^{[26, 27]}. One study used the Ruminative Responses Scale questionnaire to evaluate maladaptive coping ^[67]. The rest of the studies used coping assessment methods that were used only in some studies.

Cross-sectional studies

The results of the cross-sectional studies are presented in Table 1.

Table 1. Results of cross-sectional studies (N = 27)

Abbreviations: BDD – major depressive disorder; BR – bipolar disorder; BR 1 – type 1 bipolar disorder; BR 2 – type 2 bipolar disorder; ICD-10 – International Classification of Diseases 10th revision; DSM-4-TR – Diagnostic and Statistical Manual of Mental Disorders 4th edition (revised); MCP – mechanisms of E. Heim's coping behavior; DSM-4 - Diagnostic and Statistical Manual of Mental Disorders, 4th edition; DSM-5 - Diagnostic and Statistical Manual of Mental Disorders, 5th edition; RDC – Research Diagnostic Criteria; VOX – variants of the coping strategy questionnaire R .

First, cross-sectional studies have shown the relationship between the severity of depression symptoms and various copings. Secondly, studies show that patients with affective disorders differ from healthy people in their repertoire of coping behavior. Thirdly, a number of studies have revealed differences between clinical groups. Fourth, one study found results suggesting that coping mediates the link between childhood abuse and depressive disorder.

Longitudinal studies

The results of longitudinal studies are presented in Table 2.

Table 2. The results of longitudinal studies

Abbreviations: BDR – large depressive disorder; BD – bipolar disorder; BD 1 – bipolar disorder 1-th type; BR 2 – bipolar disorder 2-th type; VAUX – options of the questionnaire , the coping strategy of R. Lazarus; RDC, Research Diagnostic Criteria; DSM-3-R Diagnostic and statistical manual for mental disorders 3-th edition (revised); DSM-4 – Diagnostic and statistical manual for mental disorders 4-th edition; HDLF – Health and Daily Living Form; DSSI – index of the severity of depression; SCI – semi-structured Interview Course; PSE-9-R – present state examination; UCL – Utrecht Coping List; CIDI – The World Health Organization version of the Composite International Diagnostic Interview; DTC – drinking to cope; DP – drinking problems; SCID – Structured Clinical Interview; SCL-90, The 90-item Symptom Check List; HRSD – Hamilton Rating Scale for Depression; PISA – Psychiatric Initial Screening for Affective Disorder; COALA – Comprehensive Assessment List for Affective Disorders; GAS, Global Assessment Scale; PA - Physical Activity Index; ZS – Zung Scale; PHQ-9 – 9-item Patient Health Questionnaire; MINI – Mini-International Neuropsychiatric Interview; ISS – Internal State Scale; BCOPE – short version of the COPE; RPA – Responses to Positive Affect questionnaire; RSQ – Response Styles Questionnaire; CERQ - Cognitive Emotion Regulation Questionnaire; DIGS – semi-structured Diagnostic Interview for Genetic Studies; SRPRSQ – self-rating questionnaire Problem Resolution Strategy; GAF – Global Assessment of Functioning; CTQ – Childhood Trauma Questionnaire; CSI – Coping Strategies Index; EC – Exercise Coping.

In 5 studies that examined the same sample (unipolar depression), it was found that avoidant coping predicts the outcome of depression. S. Krantz and R. Moos reported that later remission is associated with avoidance at one-year follow-up ^[41]. R. Swindle et al. found that emotional release (verbal and behavioral expression of unpleasant emotions, as well as indirect efforts to reduce tension) is associated with increased symptoms of depression over a four-year period ^[64]. In another study, the results suggest that avoidant coping is associated with a higher chance of partial or no remission ^[20]. Patients with a higher level of avoidance are more likely to suffer from moderate or severe depression ^{[21, 71]}.

C. Bockting et al. obtained results indicating that avoidant coping predicts an earlier onset of relapse, but this effect varied both depending on treatment conditions and the number of previous episodes of depression. In the group receiving cognitive therapy, the association between avoidance and time to relapse decreased with an increase in the number of previous episodes. In the group receiving cognitive therapy, the association with avoidance increased with an increase in the number of previous episodes ^[11]. In one study, stress-reducing coping was found to accelerate the time to remission ^[54]. K. Yamada et al. found that ruminative coping is associated with a positive outcome, while dangerous activity is associated with a negative outcome ^[72]. Szadoczky E. and others . It has been established that coping does not predict the outcomes of depression ^[65].

Most studies have not found that problem-based strategies predict outcomes in patients with unipolar depression. ^{[11, 54, 59, 65]}. At the same time, one study found that problem-oriented coping (problem solving) predicts a decrease in symptoms of depression ^[64]. E. Woodhead et al. obtained results indicating that weaker coping patterns (low self-concept, high severity) were observed in the group of patients with severe and moderate depression. avoidance strategies, low severity of problem-oriented coping) than in patients with mild depression ^[71].

In addition, C. Hollah et al. found that alcohol consumption to combat stress increases the relationship between depression and alcohol-related behavior. In people who were initially more likely to drink alcohol to relieve stress, there was a closer association between depressive symptoms and alcohol use, as well as alcohol problems ^[34]. A. Harris et al. in the same sample obtained results indicating that higher physical activity is associated with fewer concomitant symptoms for 10 years. The authors point out that this relationship cannot be explained by age, health problems, or the presence of negative life events in the previous 3 months. Higher physical activity neutralized the effects of diseases and negative life events on depression. However, physical activity did not predict subsequent depression ^[32].

In a large study, results were obtained indicating that a high degree of depressive coping style is a risk factor for developing future depression. In addition, the authors found that coping style increased during depression, but then returned to a pre-painful level after remission ^[57]. M. Li et al. found that negative coping mediates the relationship between childhood abuse and the risk of depression. Social support, positive coping, and negative coping also influenced each other and collectively mediated the link between childhood abuse and major depressive disorder ^[47].

Only one longitudinal study was found, which included patients with bipolar disorder. The authors of the study obtained results indicating that after taking into account the initial symptoms (depression, hypomania, anxiety) and age, among all copings, only a low level of the "seeking social support" strategy predicts depression at follow-up in patients with type 1 bipolar disorder. In patients with type 2 bipolar disorder, rumination about negative mood and self-blame predicted future symptoms of depression ^[27].

The relationship of coping with the severity of symptoms of depression

In 17 studies, data on correlations between the severity of depression and coping behavior were presented. ^{[2, 10, 22, 27, 33, 36, 41, 48, 51, 55, 56, 58, 62, 63, 67, 72, 73]}.

There are 14 publications that investigated the relationship with problem-oriented coping: negative correlation — 64.2% (n = 9); lack of relationships — 35.8% (n = 5) ^{[2, 10, 27, 33, 36, 48, 51, 55, 56, 58, 62, 63, 67, 73]}. In the studies where associations were found, in six of them problem-oriented coping was considered as a separate factor. ^{[33, 51, 62, 63, 67, 73]}. Three publications have revealed correlations between depressive symptoms and coping methods such as problem solving ^{[10, 48]} and situational control ^[36].

10 papers present data on EQV: negative correlation — 90% (n = 9); lack of interrelationships — 10% (n = 1) ^{[10, 22, 27, 33, 36, 48, 55, 56, 67, 73]}. Three studies have found links for emotionally oriented coping as a separate factor ^{[33, 67, 73]}. In one study, a correlation was found between positive coping, which includes, in addition to EOQ, also problem-oriented strategies (underestimation, denial of guilt, distraction, compensatory satisfaction, situation control, positive self-instruction) ^[36]. Another study found a relationship between positive religious coping (spiritual connection, seeking spiritual support, religious forgiveness, overcoming religious problems together, etc.) and depression ^[22]. Four studies have identified correlations for coping strategies such as emotional regulation ^[10], humor ^[55], and positive reassessment ^{[27, 48]}.

In 15 studies, the results on EOKO are presented: the relationship was revealed — 86.6% (n = 13); the absence of relationships — 13.3% (n = 2) ^{[10, 22, 27, 33, 36, 41, 48, 51, 55, 56, 58, 62, 67, 72, 73]}. In seven studies that found correlations, large-scale coping measurements were evaluated. In three studies using the CISS questionnaire ("Coping Inventory for Stressful Situations"), direct correlations of emotionally oriented coping with the severity of symptoms of depression were found. However, the relationship of avoidant coping with symptoms has been inconsistent ^{[51, 58, 62]}. Emotionally oriented coping, assessed with the help of CISS, was classified as EOC, since the content of the points on this scale corresponds to detachment from a stressful situation. Three studies have shown that dysfunctional or negative coping is directly related to the severity of symptoms of depression ^{[33, 36, 73]}. Seven studies have revealed direct correlations with individual coping strategies: emotional release ^[10], rumination ^{[27, 67]}, behavioral detachment ^{[55, 56]}, avoidance ^{[41, 48]}, risk-taking and self-blame ^[27].

One study was not included, as it is impossible to unambiguously attribute the results obtained to a specific type of coping ^[2].

Comparison with healthy people

In sixteen studies, the clinical study population was compared with the control group. In each study, differences were found between the coping behavior of individuals suffering from affective disorders and healthy ones. ^{[3, 5, 6, 16, 19, 20, 23, 25, 33, 49, 55, 56, 58, 67, 69, 73]}.

15 studies provide data on problem-oriented coping: 80% (n = 12) — problem-oriented coping is less used in the clinical population than in the healthy group; 13.3% (n = 2) — no differences were found; 6.6% (n = 1) — mixed results ^{[3, 5, 6, 16, 19, 23, 25, 33, 49, 55, 56, 58, 67, 69, 73]}. In 5 studies, the results indicate that the problem-oriented type of coping is less often used by patients with affective disorders than by healthy ones. ^{[3, 33, 58, 67, 69, 73]}. In other studies, results have been obtained indicating that patients are less likely to use strategies such as planning ^{[5, 16, 23, 25, 55, 56]}, active coping or confrontation ^{[6, 16, 23, 25, 55, 56]} and suppression of competing activity ^{[55, 56]}. In one study, mixed results were obtained — patients with endogenous depression, on the one hand, used the "problem solving planning" strategy less often, and on the other hand, resorted to confrontation more often ^[5].

12 publications provided data on EQA: 50% (n = 6) — patients with affective disorders use EOCV less often than healthy ones; 16.6% (n = 2) — mixed results; 22.6% (n = 1) — EOCV is used more often in the group of affective disorders; 25% (n = 3) — no differences were found ^{[3, 6, 16, 19, 23, 25, 33, 49, 55, 56, 67, 73]}. In a study conducted by C. Ho et al., revealed that patients with major depressive disorder use emotionally oriented coping less often ^[33]. In another study, it was found that people with depression are less likely to use "cognitive restructuring" (as a factor) ^[67]. S. Choudhury et al. generally obtained results indicating that patients are less likely to use EOQ (seeking instrumental support, acceptance, positive reassessment) ^[16]. One study revealed that patients with dysthymia are less likely to use adaptive coping in the emotional and cognitive spheres ^[3]. The results of two studies indicate that patients with depression are less likely to resort to strategies such as positive reassessment ^{[55, 56]}, seeking instrumental social support ^[56], and humor ^[55]. Two publications were classified as papers with mixed results. In one study, it was revealed that patients more often use the "taking responsibility" strategy and less often the "positive reassessment" coping ^[6]. Duggar P. and others . It was found that patients with bipolar depression are more likely to use acceptance, but less often positive reassessment ^[23]. I. Crasovan and D. Crasovan reported that patients are more likely to use such a method of EQV as "acceptance" ^[19].

16 studies presented data on EKO: 93.75% (n = 15) — more often used in the group of affective disorders than in the group of healthy people; 6.25% (n = 1) — mixed results ^{[3, 5, 6, 16, 19, 20, 23, 25, 33, 49, 55, 56, 58, 67, 69, 73]}. In four studies, it was reported that patients are more likely than healthy people to resort to EKO at the level of large dimensions (dysfunctional coping, maladaptive coping in the behavioral sphere, etc.) ^{[3, 33, 69, 73]}. In other studies, results have been obtained indicating that patients are more likely to use various EKO methods than healthy ones. ^{[5, 6, 16, 19, 20, 23, 25, 49, 55, 56, 67]}. In a study using the CISS questionnaire, it was found that patients are more likely than healthy people to use emotionally oriented strategies that were previously classified as EOC based on the content of items, but less likely to use avoidance ^[58].

It should also be noted here that some results were not included in the calculation, since coping methods cannot be attributed to one type or another. Three studies have reported that patients with affective disorders are less likely to use the "humor" strategy than healthy ones ^{[16, 23, 55]}. Two studies have found that patients are more likely to resort to such a strategy as "religious coping" ^{[16, 19]}.

Comparison of clinical groups

Three studies compared patients suffering from major depressive disorder with patients suffering from bipolar disorder. One study found no significant differences in preferred coping strategies assessed using the COPE methodology ^[24]. In the study conducted by K. Fletcher et al., there were also no differences in coping assessed using the short version of COPE. However, they found that patients with depression are less likely than patients with bipolar disorder to resort to using various coping reactions, such as rumination and risk-taking ^[26]. H. Suh et al. found that patients with unipolar depression score less on the CISS scales of "avoidant coping" and "problem-oriented coping" than patients with bipolar disorder. They also found that people with bipolar disorder who are currently depressed are less likely to use problem-oriented and avoidant coping, and more likely to resort to emotionally oriented coping than patients with bipolar disorder without depression ^[62]. Considering this, it can be argued that the results obtained depend on the method of coping assessment.

Orzechowska A. et al. demonstrated that depressed patients are less likely to use the strategies of "seeking instrumental support" and "seeking emotional social support" than patients with anxiety disorders. Patients with the first episode of depression and patients with recurrent depression do not differ in the use of coping strategies ^[56]. Yamada K. and others . No differences were found between patients with major depressive disorder, patients with unspecified depression, and patients with depression with concomitant first-axis psychiatric disorder ^[72]. It is worth noting that the last two groups had a small sample size, which limits the validity of the study's conclusions. In one cross-sectional study, it was found that a group of patients with severe symptoms of depression are less likely to use active coping than patients with moderate depression ^[16]. Pairwise comparisons in a longitudinal study showed that participants in both the high- and moderate-severity depression groups used a more maladaptive coping pattern at the start of the study than in the low-severity depression group ^[71]. E. Szadoczky et al. No differences were found between the group of patients with remission and the group without remission ^[65]. C. Yesiloglu et al. It has been reported that patients with depression who have had a suicide attempt are more likely to use dysfunctional coping than patients without such an attempt ^[73].

Age and gender characteristics

7 publications examined gender characteristics in the context of coping ^{[10, 19, 23, 29, 55, 71, 72]}. Of these, differences were found in 6 studies. ^{[10, 19, 29, 55, 71, 72]}. Some researchers have found that there is a gender specificity in the use of coping methods in patients with unipolar depression: women are more likely to use emotionally oriented coping than men ^{[10, 19, 55]}. However, Woodhead E. and others . It has been reported that women use a more adaptive coping pattern ^[71]. K. Yamada et al., evaluating 4 coping strategies (rumination, active distracting reactions, cognitive distracting reactions, and dangerous activity), found that men are more likely to use dangerous activity as coping ^[72]. In one study, which involved patients with unipolar depression who had experienced violence in childhood, it was found that men were more likely to use problem-oriented and avoidance strategies than women, but there were no differences in the use of emotionally oriented strategies ^[29]. A study involving individuals with bipolar depression found no gender differences in coping preferences ^[23].

As for age characteristics, the obtained research results do not represent consistent data on the relationship between coping and age among the studied clinical population. ^{[10, 36, 47, 62, 71, 72]}. Only one study compared groups of different ages. It was found that people aged 50 to 64 years are more likely to use problem-oriented coping than people aged 20 to 34 years ^[53].

Discussion

The relationship of coping with the severity of depression

Most studies have found inverse correlations of problem-oriented coping and EQV with symptoms of depression, as well as direct correlations between coping aimed at withdrawal or avoidance and the severity of depression.

A. Beck points out that in severe depression, resources are withdrawn from adaptive circuits (the ability to cope with difficulties and solve problems) and redistributed towards internal processes (sadness, negative cognitions). Cognitive circuits with a negative bias function as automatic processes that are fast, involuntary, and save resources. The dominance of this system (effective but maladaptive) may be the cause of negative attention and bias in interpretation. On the contrary, during depression, the role of the cognitive control system (consisting of executive functions, problem solving, and reappraisal) decreases. The work of this system is purposeful, reflexive and requires efforts (resources) ^[9]. This, in turn, can affect the stress management process in the following ways. According to the theory of stress and coping by R. Lazarus et al., secondary cognitive assessment is related to resources and coping options (is it possible to take any actions necessary to improve a person's relationship with a stressful situation). If resources are assessed as low, then emotionally oriented, avoidant strategies are most likely to be used. If resources are assessed as sufficient, problem-oriented coping will be used ^[42-45]. Based on these theoretical assumptions, we can say that the more pronounced the symptoms of depression, the greater the redistribution of resources towards internal processes. This, in turn, increases the severity of avoidance strategies, since these strategies contribute to the rapid reduction of actual internal stress and do not require large expenditures of resources. In addition, severe symptoms of depression reduce the likelihood of actualizing problem-oriented strategies and EOCs, as they require effort and resources. Thus, the depressive state affects the change in the severity of certain strategies. An indirect confirmation of this conclusion is the results that the depressive coping pattern increases during depression, but returns to a pre-painful level during remission ^[57].

It is worth emphasizing that in most studies, depression has been assessed using various self-reporting methods, which may not actually reflect the true relationships. For example, one study showed that a subjective assessment of severity (a patient's self-assessment of their condition) and an objective assessment of severity (a specialist's assessment of their condition) are related to coping strategies in different ways ^[36].

Coping as a predictor of depression

The results of longitudinal studies seem to indicate that avoidant coping (EOC) is associated with negative outcomes (late remission, higher symptoms of depression, etc.) in patients with unipolar depression. This can be explained by the fact that avoidance strategies lead to the fact that a problem or stressful situation is not resolved, persists and can develop, thereby bringing even more distress in the future, worsening the outcome of depression. These results are consistent with the model of stress generation and coping. C. Holahan et al. A 10-year longitudinal study was conducted, which involved 1,211 adults aged 55 to 65 years at the start of the study. They found that avoidant coping predicted an increase in the number of chronic and acute stressors after four years, which, in turn, predicted an increase in depressive symptoms ^[35].

As for problem-oriented coping and EOC, the results of longitudinal studies do not provide consistent evidence that these types of coping predict depression outcomes in patients with unipolar depression. In addition, one longitudinal study found that, depending on the type of bipolar disorder, different coping methods are involved in predicting future depression in different ways.

Our results are consistent with the data from the review by M. Christensen and L. Kessing, who indicated that emotionally oriented and avoidant coping methods are associated with depression outcomes in patients with affective disorders ^[17].

In one longitudinal study, the results were presented, according to which physical exercise as coping reduces the level of depression and neutralizes the influence of negative events and diseases on depression ^[32]. Physical exercise has an antidepressant effect through several biological and psychosocial channels. For example, physical exercise can increase self-efficacy, which in turn can have a positive effect on other areas of life and counteract the symptoms of depression ^[38]. One study also examined the relationship between coping alcohol use and depression. Depressive symptoms have been found to be significantly associated with an increase in alcohol-related problems ^[34]. Alcohol, being a typical depressant, affects the brain and, with further consumption, can increase the symptoms of depression ^[60].

Our review presents one study with a large sample that shows that depressive coping style is a risk factor for depression in healthy people ^[57], which can also be explained through the stress generation model discussed above ^[35].

Ways to overcome stressful situations are not based on isolated adaptation, but rather mediate the relationship of other psychosocial parameters with the results of adaptation. Previous psychosocial parameters include stressor characteristics (both distal and close stressors), social context, dispositional characteristics, and cognitive processes ^[66]. One longitudinal study found that negative coping mediates the relationship between childhood abuse and the risk of depression. Positive coping did not act as a mediator ^[47]. However, in one cross-sectional study, it was found that positive coping mediates such a relationship and is negatively associated with the formation of major depressive disorder ^[63]. These differences can be explained by different research methodologies, including differences in coping assessment methods.

Coping Profile

Based on the results of comparing people with depression and healthy people, the following can be said. Firstly, people suffering from depression are less likely to use problem-oriented coping strategies than healthy people. Secondly, people with depression are more likely to resort to EKO. As for the EOC, the results are less consistent.

The data obtained can be explained as follows. As mentioned earlier, the coping process depends on cognitive assessment. People with depression often underestimate the controllability and variability of the situation, which can lead to passivity rather than active interaction with a stressful situation ^[1]. This, in turn, may explain the observed coping pattern. The results are also consistent with the theoretical positions of A. Beck, who argued that resources are redistributed towards internal processes and withdrawn from adaptive schemes ^[9]. J. Trew presented an integrative model that considers depression from the perspective of two fundamental motivational principles: the desire to achieve positive results ("approach") and the desire to avoid negative results (English "avoidance"). After reviewing existing research, the author argues that depression is characterized by a deficit in the desire for intimacy and increased avoidance, which in turn leads to a decrease in positive reinforcing experiences, increased negative experiences, and contributes to the onset and maintenance of depression ^[68]. In the context of this model, the results obtained can be interpreted as follows: the deficit of problem-oriented coping as a reflection of the deficit of the desire for rapprochement, and the preference for avoidance strategies as a manifestation of increased avoidance of negative results.

As for the differences in coping behavior between clinical groups, there are few studies that have explored this topic. Further research is needed to determine the coping profiles that differentiate the clinical groups.

Gender and age.

It was found that patients with unipolar depression have gender-specific coping preferences: women are more likely to resort to emotionally oriented coping strategies than men. This is generally consistent with the fact that women are more likely to prefer emotionally-oriented coping methods. There are several explanations, for example, based on the hypothesis of socialization, men are socialized to use more active and instrumental behavior, while women are socialized to use more passive and emotionally oriented behavior ^[50]. It also seems that the concomitant experience of child abuse and the type of depression (bipolar depression) can change the gender specifics of coping behavior, but the limited number of studies does not allow us to draw unambiguous conclusions.

As for age, the studies reviewed in this paper do not provide consistent data on how age is associated with coping in the study population. Various correlations between age and coping strategies have been found in individual publications. Oh M. et al. found that people with depression aged 20-34 years are less likely to use "problem solving" strategies than older patients. The authors explain this by saying that young people tend to be more anxious, depressed, and disappointed than older people (high levels of neuroticism). They lack tolerance, altruism (low levels of benevolence), as well as self-control, sincerity, and prudence (low levels of conscientiousness). This can lead them to deal with stress passively, negatively, and impulsively rather than directly, which can increase their vulnerability to depression ^[53]. There is evidence that stress management skills are formed and developed throughout life and vary between age groups ^{[4, 8, 61]}.

Ways to evaluate coping.

As can be seen from our results, coping has been evaluated in different ways in research, which makes it difficult to analyze, summarize, and compare data. The coping rates in all the studies included in the review were based on self-reports. The research used various scales and questionnaires without any "gold standard". For example, it was found that researchers often use the COPE questionnaire and its short version. However, the different orientation (goals and objectives), characteristics of the samples, and other differences between the studies do not allow us to reliably summarize the data obtained using this questionnaire. In addition, most of the methods used in the analyzed papers have a number of disadvantages. For example, the questionnaire "The Coping Inventory for Stress Situation" is limited to three factors that do not reflect actual coping ^[1]. It is also worth considering that questionnaires have a number of other problems, such as the inability to assess the dynamic characteristics of coping, unreliability of memories of specific behavior, and others ^{[1, 4, 28]}. Various coping assessment methods have been developed in connection with this problem. For example, methods such as daily coping assessment and environmental instant assessment methods have been developed ^[28].

Personality and coping

Coping is closely related to personality. In a 2007 meta-analysis, results were obtained indicating that optimism, extraversion, conscientiousness, and openness contribute to more active coping with difficulties, while neuroticism, on the contrary, contributes to more passive coping with difficulties. The authors also found that optimism, conscientiousness, and benevolence are associated with less passive coping strategies ^[18]. N. Bolger and A. Zuckerman described ways in which personality and coping can jointly influence adaptation. First, there is the mediation model, which assumes that personality influences the choice of coping strategies, which, in turn, influence the outcome of adaptation. Another way is the moderation model, which assumes that personality influences the effectiveness of a coping strategy ^[12]. In this review, no studies were found on the interaction of coping behavior and personality in patients with affective disorders.

Conclusion

A systematic review was conducted on the topic of coping and depression among people suffering from affective disorders. The results obtained indicate that the symptoms of depression are negatively associated with problem-oriented coping and emotionally-oriented coping aimed at involving stress in a situation, and avoidant coping is directly related to the severity of symptoms of depression. As for the predictive power of coping, the results of longitudinal studies indicate that avoidant coping is associated with negative outcomes in patients with unipolar depression. However, the results of research on problem-oriented coping and emotion-oriented coping, aimed at involving stress in a situation, do not provide evidence of their predictive power. Only one study was found in which coping was studied as a risk factor for the development of depressive disorder in healthy people. The results of two studies have shown that coping mediates the relationship between childhood abuse and depression. The results of the current review indicate that patients with depression use problem-oriented coping less often and resort to avoidant coping more often than healthy people. It has been revealed that there is a shortage of studies comparing coping profiles between different clinical groups. Regarding gender and age characteristics, a limited amount of research on this issue has also been found. Apparently, the results indicate that there is a gender-specific repertoire of coping behavior in unipolar depression: women are more likely to use emotionally oriented strategies than men. The results regarding age characteristics and coping do not provide consistent evidence. It was revealed that the researchers use different techniques. This, in turn, makes it difficult to analyze, summarize, and compare data. No studies have been found that have investigated the interaction of coping with personality traits.

It is worth noting a number of main limitations of the current review. Firstly, one author participated in the search and selection of publications, as well as in the recoding of research results, which may be a source of bias in the review. Secondly, some publications were not available, which may lead to a distortion of the overall picture of the problem under study. Third, the studies included in the review were significantly diverse, including ethnic diversity, which is known to influence the association between coping behavior and depression ^[15]. In this regard, some provisions of the review should be considered as preliminary, requiring further verification as empirical material accumulates.

Future researchers in the field of coping and depression may focus on the predictive role of coping in the development of depressive disorder in healthy individuals, the age and gender characteristics of patients with affective disorders, cross-cultural differences, and the interaction between coping and personality. In addition, coping assessment methods can be used to take into account its dynamic characteristics.